1
|
Catarci M, Guadagni S, Masedu F, Ruffo G, Viola MG, Scatizzi M. Bowel preparation before elective right colectomy: Multitreatment machine-learning analysis on 2,617 patients. Surgery 2024:S0039-6060(24)00675-5. [PMID: 39322486 DOI: 10.1016/j.surg.2024.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 08/13/2024] [Accepted: 08/29/2024] [Indexed: 09/27/2024]
Abstract
BACKGROUND In the worldwide, real-life setting, some candidates for right colectomy still receive no bowel preparation, some receive oral antibiotics alone, some receive mechanical bowel preparation alone, and some receive mechanical bowel preparation with oral antibiotics, with varying degrees of compliance to preoperative intravenous antibiotic prophylaxis. Previous studies mainly focused on left-sided colorectal anastomoses while less attention has been devoted to right-sided ileocolic anastomoses. When high-level evidence from randomized clinical trials is lacking, multiple-treatment propensity score weighting analysis of prospective data on the basis of generalized boosted model is superior to a simple propensity score-matching analysis and to an inverse probability weighting in terms of external validity and bias reduction. METHODS This is an analysis on the basis of machine-learning procedures of 2,617 patients who underwent elective right colectomies. RESULTS The risk of surgical-site infections (5.0% after no bowel preparation) was significantly lower after mechanical bowel preparation with oral antibiotics (4.0%, P = .017), significantly greater after mechanical bowel preparation alone (8.6%, P = .019), and comparable after oral antibiotics alone (3.9%). The risk of anastomotic leakage (3.2% after no bowel preparation) was significantly greater after oral antibiotics alone (4.8%, P = .013). Concerning secondary outcomes, no significant differences were recorded for the risk of overall morbidity and reoperation. The risk of readmission (3.0% after no bowel preparation) was significantly reduced after mechanical bowel preparation with oral antibiotics (1.5%, P = .046), and the risk of major morbidity (5.1% after no bowel preparation) was significantly greater after oral antibiotics alone (6.7%, P = .007). CONCLUSION This multitreatment machine-learning analysis, despite some limitations, showed that mechanical bowel preparation with oral antibiotics is associated with a decrease in surgical-site infections after elective right colectomy compared with no bowel preparation.
Collapse
Affiliation(s)
- Marco Catarci
- General Surgery Unit, Sandro Pertini Hospital, Roma, Italy
| | - Stefano Guadagni
- General Surgery Unit, Università degli Studi dell'Aquila, L'Aquila, Italy.
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Università degli Studi dell'Aquila, L'Aquila, Italy
| | - Giacomo Ruffo
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Province of Verona, Italy
| | | | - Marco Scatizzi
- General Surgery Unit, Santa Maria Annunziata & Serristori Hospital, Florence, Italy
| |
Collapse
|
2
|
Boatman S, Khan MH, Ganesan N, Nalluri-Butz H, Kohn J, Troester A, Ziegert Z, Madoff R, Gaertner WB, Jahansouz C, Staley C. Anastomotic leak occurs independently from microbiota shifts associated with surgical bowel preparation. Sci Rep 2024; 14:21711. [PMID: 39289419 PMCID: PMC11408509 DOI: 10.1038/s41598-024-72520-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 09/09/2024] [Indexed: 09/19/2024] Open
Abstract
Following bowel surgery, infectious complications, including anastomotic leak (AL), remain major sources of morbidity and mortality. Bowel preparation is often administered with the assumption that gut decontamination reduces post-surgical complications. In this study, we tested this hypothesis using a murine model of colon surgery. The mice were fed either regular chow or a high-fat, high-sugar Western diet. The day before surgery, the mice received one of four interventions: water (control), mechanical bowel preparation (MBP), oral antibiotics (OA), or both MBP and OA. We found no differences in the rates of AL among the experimental groups, and diet did not appear to affect the outcomes. Exploratory analyses showed changes in the gut microbiome consistent with the different treatments, but investigations of fecal short-chain fatty acids and RNA sequencing of colonic tissue did not reveal specific effects of the treatments or the presence of AL. However, we did identify bacterial genera that may be causally associated with AL and developed a predictive index from stool samples as a marker for the presence of AL. Future research is needed to identify and validate a microbial predictive tool and to uncover the microbial-driven mechanisms that lead to AL.
Collapse
Affiliation(s)
- Sonja Boatman
- Basic and Translational Research, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MCC 195, Minneapolis, MN, 55455, USA
| | - Mohammad Haneef Khan
- Basic and Translational Research, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MCC 195, Minneapolis, MN, 55455, USA
| | - Nirupa Ganesan
- Basic and Translational Research, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MCC 195, Minneapolis, MN, 55455, USA
| | - Harika Nalluri-Butz
- Basic and Translational Research, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MCC 195, Minneapolis, MN, 55455, USA
| | - Julia Kohn
- Basic and Translational Research, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MCC 195, Minneapolis, MN, 55455, USA
| | - Alexander Troester
- Basic and Translational Research, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MCC 195, Minneapolis, MN, 55455, USA
| | - Zachary Ziegert
- Basic and Translational Research, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MCC 195, Minneapolis, MN, 55455, USA
| | - Robert Madoff
- Basic and Translational Research, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MCC 195, Minneapolis, MN, 55455, USA
- Division of Colon and Rectal Surgery, University of Minnesota, 420 Delaware Street SE, MMC 450, Minneapolis, MN, 55455, USA
| | - Wolfgang B Gaertner
- Basic and Translational Research, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MCC 195, Minneapolis, MN, 55455, USA
- Division of Colon and Rectal Surgery, University of Minnesota, 420 Delaware Street SE, MMC 450, Minneapolis, MN, 55455, USA
| | - Cyrus Jahansouz
- Basic and Translational Research, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MCC 195, Minneapolis, MN, 55455, USA.
- Division of Colon and Rectal Surgery, University of Minnesota, 420 Delaware Street SE, MMC 450, Minneapolis, MN, 55455, USA.
| | - Christopher Staley
- Basic and Translational Research, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MCC 195, Minneapolis, MN, 55455, USA.
- BioTechnology Institute, University of Minnesota, St. Paul, MN, 55108, USA.
| |
Collapse
|
3
|
Catarci M, Guadagni S, Masedu F, Ruffo G, Viola MG, Borghi F, Garulli G, Pirozzi F, Delrio P, De Luca R, Baldazzi G, Scatizzi M. Bowel preparation for elective colorectal resection: multi-treatment machine learning analysis on 6241 cases from a prospective Italian cohort. Int J Colorectal Dis 2024; 39:53. [PMID: 38625550 PMCID: PMC11021318 DOI: 10.1007/s00384-024-04627-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Current evidence concerning bowel preparation before elective colorectal surgery is still controversial. This study aimed to compare the incidence of anastomotic leakage (AL), surgical site infections (SSIs), and overall morbidity (any adverse event, OM) after elective colorectal surgery using four different types of bowel preparation. METHODS A prospective database gathered among 78 Italian surgical centers in two prospective studies, including 6241 patients who underwent elective colorectal resection with anastomosis for malignant or benign disease, was re-analyzed through a multi-treatment machine-learning model considering no bowel preparation (NBP; No. = 3742; 60.0%) as the reference treatment arm, compared to oral antibiotics alone (oA; No. = 406; 6.5%), mechanical bowel preparation alone (MBP; No. = 1486; 23.8%), or in combination with oAB (MoABP; No. = 607; 9.7%). Twenty covariates related to biometric data, surgical procedures, perioperative management, and hospital/center data potentially affecting outcomes were included and balanced into the model. The primary endpoints were AL, SSIs, and OM. All the results were reported as odds ratio (OR) with 95% confidence intervals (95% CI). RESULTS Compared to NBP, MBP showed significantly higher AL risk (OR 1.82; 95% CI 1.23-2.71; p = .003) and OM risk (OR 1.38; 95% CI 1.10-1.72; p = .005), no significant differences for all the endpoints were recorded in the oA group, whereas MoABP showed a significantly reduced SSI risk (OR 0.45; 95% CI 0.25-0.79; p = .008). CONCLUSIONS MoABP significantly reduced the SSI risk after elective colorectal surgery, therefore representing a valid alternative to NBP.
Collapse
Affiliation(s)
- Marco Catarci
- General Surgery Unit, Sandro Pertini Hospital, ASL Roma 2, Rome, Italy
| | - Stefano Guadagni
- General Surgery Unit, Università degli Studi dell'Aquila, Via Vetoio, snc, 67100, L'Aquila, Italy.
- Department of Biotechnological and Applied Clinical Sciences, Università degli Studi dell'Aquila, L'Aquila, Italy.
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Università degli Studi dell'Aquila, L'Aquila, Italy
| | - Giacomo Ruffo
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, VR, Italy
| | | | - Felice Borghi
- Oncologic Surgery Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, TO, Italy
| | | | - Felice Pirozzi
- General Surgery Unit, ASL Napoli2 , Nord, Pozzuoli, NA, Italy
| | - Paolo Delrio
- Colorectal Surgical Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori, Fondazione Giovanni Pascale IRCCS-Italia", Naples, Italy
| | - Raffaele De Luca
- Department of Surgical Oncology, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | | | - Marco Scatizzi
- General Surgery Unit, Serristori Hospital, Santa Maria Annunziata &, Florence, Italy
| |
Collapse
|
4
|
Catarci M, Guadagni S, Masedu F, Sartelli M, Montemurro LA, Baiocchi GL, Tebala GD, Borghi F, Marini P, Scatizzi M, The Italian ColoRectal Anastomotic Leakage iCral Study Group. Oral Antibiotics Alone versus Oral Antibiotics Combined with Mechanical Bowel Preparation for Elective Colorectal Surgery: A Propensity Score-Matching Re-Analysis of the iCral 2 and 3 Prospective Cohorts. Antibiotics (Basel) 2024; 13:235. [PMID: 38534670 DOI: 10.3390/antibiotics13030235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/28/2024] Open
Abstract
The evidence regarding the role of oral antibiotics alone (oA) or combined with mechanical bowel preparation (MoABP) for elective colorectal surgery remains controversial. A prospective database of 8359 colorectal resections gathered over a 32-month period from 78 Italian surgical units (the iCral 2 and 3 studies), reporting patient-, disease-, and procedure-related variables together with 60-day adverse events, was re-analyzed to identify a subgroup of 1013 cases (12.1%) that received either oA or MoABP. This dataset was analyzed using a 1:1 propensity score-matching model including 20 covariates. Two well-balanced groups of 243 patients each were obtained: group A (oA) and group B (MoABP). The primary endpoints were anastomotic leakage (AL) and surgical site infection (SSI) rates. Group A vs. group B showed a significantly higher AL risk [14 (5.8%) vs. 6 (2.5%) events; OR: 3.77; 95%CI: 1.22-11.67; p = 0.021], while no significant difference was recorded between the two groups regarding SSIs. These results strongly support the use of MoABP for elective colorectal resections.
Collapse
Affiliation(s)
- Marco Catarci
- General Surgery Unit, Sandro Pertini Hospital, ASL Roma 2, 00157 Roma, Italy
| | - Stefano Guadagni
- General Surgery Unit, University of L'Aquila, 67100 L'Aquila, Italy
| | - Francesco Masedu
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, 67100 L'Aquila, Italy
| | - Massimo Sartelli
- General Surgery Unit, Santa Lucia Hospital, 62100 Macerata, Italy
| | | | - Gian Luca Baiocchi
- General Surgical Unit, Department of Clinical and Experimental Sciences, University of Brescia at the Azienda Socio Sanitaria Territoriale (ASST), 26100 Cremona, Italy
| | | | - Felice Borghi
- Oncologic Surgery Unit, Candiolo Cancer Institute, FPO-IRCCS, 10060 Candiolo, Italy
| | - Pierluigi Marini
- General & Emergency Surgery Unit, San Camillo-Forlanini Hospital, 00152 Roma, Italy
| | - Marco Scatizzi
- General Surgery Unit, Santa Maria Annunziata & Serristori Hospital, 50012 Firenze, Italy
| | | |
Collapse
|
5
|
Abernethy EK, Aly EH. Postoperative Ileus after Minimally Invasive Colorectal Surgery: A Summary of Current Strategies for Prevention and Management. Dig Surg 2024; 41:79-91. [PMID: 38359801 PMCID: PMC11025667 DOI: 10.1159/000537805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 02/12/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Postoperative ileus (POI) is one of the most common postoperative complications after colorectal surgery and prolongs hospital stays. Minimally invasive surgery (MIS) has reduced POI, but it remains common. This review explores the current methods for preventing and managing POI after MIS. SUMMARY Preoperative interventions, including optimising nutrition, preoperative medicationn, and mechanical bowel preparation with oral antibiotics, may have a role in preventing POI. Transversus abdominis plane blocks and lidocaine could replace epidural analgesia in MIS. Fluid overload should be avoided; in some cases, goal-directed fluid therapy may aid in achieving this. Pharmacological agents, such as prucalopride and dexmedetomidine, could target mechanisms underlying POI. New strategies to stimulate vagal nerve activity may promote postoperative gastrointestinal motility. Preoperative bowel stimulation could potentially reduce POI following loop ileostomy closure. However, the evidence base for several interventions remains weak and requires further corroboration with robust studies. KEY MESSAGES Despite the increasing use of MIS, POI remains a major issue following colorectal surgery. Further strategies to prevent POI are rapidly emerging. Studies using standardised definitions and perioperative care will help validate these interventions and remove barriers to accurate meta-analysis. Future studies should focus on establishing the impact of these interventions on POI after MIS specifically.
Collapse
Affiliation(s)
| | - Emad H Aly
- University of Aberdeen, Aberdeen, UK
- Aberdeen Royal Infirmary, Aberdeen, UK
| |
Collapse
|
6
|
Yao J, Chen L, Liu X, Wang J, Zeng J, Cai Y. Meta-analysis of efficacy of perioperative oral antibiotics in intestinal surgery with surgical site infection. J Glob Antimicrob Resist 2023; 35:223-236. [PMID: 37797809 DOI: 10.1016/j.jgar.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/27/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVES Surgical site infection (SSI) is a serious complication of intestinal surgery. In this meta-analysis, we aimed to explore the efficacy and safety of different preoperative oral antibiotic preparation (OABP) compared with intravenous antibiotic preparation (IVAP) and/or mechanical bowel preparation (MBP). METHODS A meta-analysis consisting of adult patients adopting oral antibiotics versus other regimens during the preoperative preparation of elective intestinal surgery was performed. The outcome included overall SSI, organ space SSI, superficial SSI, deep SSI, and mortality rate. RESULTS A total of 35 randomized controlled trials (RCTs) consisting of 8445 adult patients were included in our present analysis. OABP regimens were combined with IVAP in 29 RCTs. In general, the incidence of overall SSI in the OABP group was less compared with the IVAP alone or IVAP+MBP group (RR 0.56, 95% CI 0.46-0.69, P < .00001, I2 = 47%). Metronidazoles plus quinolones or aminoglycosides showed the best effect on reducing the overall SSI. OABP in combination with preoperative and postoperative IVAP was both significantly associated with reduced SSI. IVAP before and within 24 h after surgery showed the best advantage. No difference was found between the OABP without IVAP group and the control group in reducing SSI. OABP regimens also demonstrated a lower incidence rate of organ space SSI, superficial SSI, deep SSI, and mortality. CONCLUSION OABP in combination with preoperative IVAP and within 24 h post-operation significantly reduced the incidence of SSI in intestinal surgery. Metronidazoles accompanied with quinolones or aminoglycosides might be the appropriate combinations for OABP regimens.
Collapse
Affiliation(s)
- Jiahui Yao
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center, PLA General Hospital, Beijing, China
| | - Li Chen
- Department of information, PLA General Hospital, Beijing, China
| | - Xiaoli Liu
- Department of Dermatology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jin Wang
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center, PLA General Hospital, Beijing, China
| | - Jinru Zeng
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center, PLA General Hospital, Beijing, China.
| | - Yun Cai
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center, PLA General Hospital, Beijing, China.
| |
Collapse
|
7
|
Na JE, Kim ER, Kim JE, Hong SN, Kim YH, Chang DK. The optimal surgery timing after stenting in colorectal cancer patients with malignant obstruction: additionally compared with emergency surgery. World J Surg Oncol 2023; 21:259. [PMID: 37612670 PMCID: PMC10463965 DOI: 10.1186/s12957-023-03130-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 07/29/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND This study aimed to determine short-term and long-term outcomes according to time intervals after stenting and compared them with those of emergency surgery (ES) in colorectal cancer (CRC) with malignant obstruction. METHODS CRC with malignant obstructions was reviewed retrospectively between January 2008 and July 2018. Of a total of 539 patients who visited the emergency room and underwent ES, 133 were enrolled in the ES group. Of a total of 567 patients who initially received stenting and subsequently underwent elective surgery, 220 were enrolled in the SEMS group. The interval between SEMS placement and elective surgery was classified as < 11 days, 11-17 days, and > 17 days. RESULTS For those who received SEMS (n = 220), those with a time interval of 11-17 days (n = 97) had fewer hospital days than those with a time interval of < 11 days (n = 68) (8 days vs. 15 days) and less stoma formation than those with a time interval of > 17 days (n = 55) (1.0% vs. 14.6%). Multivariable analysis revealed a decreased risk of death for the group with a time interval of 11-17 days (20.6%) compared to the ES group (31.6%) (hazard ratio: 0.48; 95% confidence interval: 0.24-0.97). Disease-free survival was comparable between the SEMS and ES groups regardless of the time interval (log-rank p = 0.52). CONCLUSIONS The time interval of 11-17 days after stenting to elective surgery appeared to be associated with the most favorable outcomes.
Collapse
Affiliation(s)
- Ji Eun Na
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
- Department of Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea.
| | - Ji Eun Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Sung Noh Hong
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Young Ho Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Dong Kyung Chang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| |
Collapse
|
8
|
Gillespie BM, Harbeck EL, Sandy-Hodgetts K, Rattray M, Thalib L, Patel B, Andersson AE, Walker RM, Latimer S, Chaboyer WP. Incidence of wound dehiscence in patients undergoing laparoscopy or laparotomy: a systematic review and meta-analysis. J Wound Care 2023; 32:S31-S43. [PMID: 37591664 DOI: 10.12968/jowc.2023.32.sup8a.s31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
Surgical wound dehiscence (SWD) is a serious complication-with a 40% estimated mortality rate-that occurs after surgical intervention. Since the implementation of advanced recovery protocols, the current global incidence of SWD is unknown. This systematic review and meta-analysis estimated the worldwide incidence of SWD and explored its associated factors in general surgical patients. Eligible full-text cross-sectional, cohort and observational studies in English, between 1 January 2010 to 23 April 2021, were retrieved from MEDLINE, CINAHL, EMBASE and the Cochrane Library. Data extraction and quality appraisal were undertaken independently by three reviewers. Random effects meta-analytic models were used in the presence of substantial inconsistency. Subgroup, meta-regression and sensitivity analyses were used to explore inconsistency. Publication bias was assessed using Hunter's plots and Egger's regression test. Of 2862 publications retrieved, 27 studies were included in the final analyses. Pooled data from 741,118 patients across 24 studies were meta-analysed. The 30-day cumulative incidence of SWD was 1% (95% Confidence Interval (CI): 1-1%). SWD incidence was highest in hepatobiliary surgery, at 3% (95% CI: 0-8%). Multivariable meta-regression showed SWD was significantly associated with duration of operation and reoperation (F=7.93 (2-10); p=0.009), explaining 58.2% of the variance. Most studies were retrospective, predated the agreed global definition for SWD and measured as a secondary outcome; thus, our results likely underestimate the scope of the problem. Wider uptake of the global definition will inform the SWD surveillance and improve the accuracy of reporting.
Collapse
Affiliation(s)
- Brigid M Gillespie
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Griffith University, Australia
- Gold Coast University Hospital, Gold Coast Health Nursing and Midwifery Education and Research Unit, Queensland, Australia
| | - Emma L Harbeck
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Griffith University, Australia
| | - Kylie Sandy-Hodgetts
- School of Biomedical Sciences, University of Western Australia Centre for Molecular Medicine and Innovative Therapeutics, Murdoch University, Australia
| | - Megan Rattray
- Menzies Health Institute Queensland, Griffith University, Australia
| | - Lukman Thalib
- Department of Biostatistics, Faculty of Medicine, Istanbul Aydın University, Istanbul, Turkey
| | - Bhavik Patel
- Acute Care and Trauma Surgery, Gold Coast University Hospital, Queensland, Australia
| | - Annette Erichsen Andersson
- Institute of Health Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Rachel M Walker
- School of Nursing and Midwifery, Griffith University, Queensland, Australia
- Division of Surgery, Princess Alexandra Hospital, Queensland, Australia
| | - Sharon Latimer
- School of Nursing and Midwifery, Griffith University, Queensland, Australia
| | - Wendy P Chaboyer
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Griffith University, Australia
| |
Collapse
|
9
|
Schudrowitz N, Shahan CP, Moss T, Scarborough JE. Bowel Preparation Before Nonelective Sigmoidectomy for Sigmoid Volvulus: Highly Beneficial but Vastly Underused. J Am Coll Surg 2023; 236:649-655. [PMID: 36695556 DOI: 10.1097/xcs.0000000000000593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Although strong evidence exists for combined mechanical and oral antibiotic bowel preparation before elective colorectal resection, the utility of preoperative bowel preparation for patients undergoing sigmoid resection after endoscopic decompression of sigmoid volvulus has not been previously examined. The goal of this study was to evaluate the association between bowel preparation and postoperative outcomes for patients undergoing semielective, same-admission sigmoid resection for acute volvulus. STUDY DESIGN Patients from the 2012 to 2019 Colectomy-Targeted American College of Surgeons NSQIP dataset who underwent sigmoid resection with primary anastomosis after admission for sigmoid volvulus were included. Multivariable logistic regression was used to compare the risk-adjusted 30-day postoperative outcomes of patients who received combined preoperative bowel preparation with those of patients who received either partial (mechanical or oral antibiotic alone) or incomplete bowel preparation. Effort was made to exclude patients whose urgency of clinical condition at hospital admission precluded an attempt at preoperative decompression and subsequent bowel preparation. RESULTS Included were 2,429 patients, 322 (13.3%) of whom underwent complete bowel preparation and 2,107 (86.7%) of whom underwent partial or incomplete bowel preparation. Complete bowel preparation was protective against several postoperative complications (including anastomotic leak), mortality, and prolonged postoperative hospitalization. CONCLUSIONS This study demonstrates a significant benefit for complete bowel preparation before semielective, same-admission sigmoid resection in patients with acute sigmoid volvulus. However, only a small percentage of patients in this national sample underwent complete preoperative bowel preparation. Broader adoption of bowel preparation may reduce overall rates of complication in patients who require sigmoid colectomy due to volvulus.
Collapse
Affiliation(s)
- Natalie Schudrowitz
- From the Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | | |
Collapse
|
10
|
Baeza-Murcia M, Valero-Navarro G, Pellicer-Franco E, Soria-Aledo V, Mengual-Ballester M, Garcia-Marin JA, Betoret-Benavente L, Aguayo-Albasini JL. Bundles reduce anastomosis leak in patients undergoing elective colorectal surgery. A propensity score-matched study. Front Surg 2023; 10:1119236. [PMID: 36923382 PMCID: PMC10008907 DOI: 10.3389/fsurg.2023.1119236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/01/2023] [Indexed: 02/28/2023] Open
Abstract
Background anastomosis leak still being a handicap in colorectal surgery. Bowel mechanical preparation and oral antibiotics are not a practice recommended in many clinical practice guides. The aim is to analyse the decrease in frequency and severity of postoperative complications, mainly related to anastomotic leak, after the establishment of a bundle. Methods Single-center, before-after study. A bundle was implemented to reduce anastomotic leaks and their consequences. The Bundle group were matched to Pre-bundle group by propensity score matching. Mechanical bowel preparation, oral and intravenous antibiotics, inflammatory markers measure and early diagnosis algorithm were included at the bundle. Results The bundle group shown fewer complications, especially in Clavien Dindós Grade IV complications (2.3% vs. 6.2% p < 0.01), as well as a lower rate of anastomotic leakage (15.5% vs. 2.2% p < 0.01). A significant decrease in reinterventions, less intensive unit care admissions, a shorter hospital stay and fewer readmissions were also observed. In multivariate analysis, the application of a bundle was an anastomotic leakage protective factor (OR 0.121, p > 0.05). Conclusions The implementation of our bundle in colorectal surgery which include oral antibiotics, mechanical bowel preparation and inflammatory markers, significantly reduces morbidity adjusted to severity of complications, the anastomotic leakage rate, hospital stay and readmissions. Register study The study has been registered at clinicaltrials.gov Code: nct04632446.
Collapse
Affiliation(s)
- M Baeza-Murcia
- Servicio de Cirugía General y Digestiva, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - G Valero-Navarro
- Servicio de Cirugía General y Digestiva, Hospital General Universitario Morales Meseguer, Murcia, Spain.,Grupo de Investigación Quirurgica en Area de Salud, Instituto Murciano de Investigación Biosanitaria Pascual Parrilla, Murcia, Spain
| | - E Pellicer-Franco
- Servicio de Cirugía General y Digestiva, Hospital General Universitario Morales Meseguer, Murcia, Spain.,Grupo de Investigación Quirurgica en Area de Salud, Instituto Murciano de Investigación Biosanitaria Pascual Parrilla, Murcia, Spain
| | - V Soria-Aledo
- Servicio de Cirugía General y Digestiva, Hospital General Universitario Morales Meseguer, Murcia, Spain.,Grupo de Investigación Quirurgica en Area de Salud, Instituto Murciano de Investigación Biosanitaria Pascual Parrilla, Murcia, Spain
| | - M Mengual-Ballester
- Servicio de Cirugía General y Digestiva, Hospital General Universitario Morales Meseguer, Murcia, Spain.,Grupo de Investigación Quirurgica en Area de Salud, Instituto Murciano de Investigación Biosanitaria Pascual Parrilla, Murcia, Spain
| | - J A Garcia-Marin
- Servicio de Cirugía General y Digestiva, Hospital General Universitario Morales Meseguer, Murcia, Spain.,Grupo de Investigación Quirurgica en Area de Salud, Instituto Murciano de Investigación Biosanitaria Pascual Parrilla, Murcia, Spain
| | - L Betoret-Benavente
- Servicio de Cirugía General y Digestiva, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - J L Aguayo-Albasini
- Servicio de Cirugía General y Digestiva, Hospital General Universitario Morales Meseguer, Murcia, Spain.,Grupo de Investigación Quirurgica en Area de Salud, Instituto Murciano de Investigación Biosanitaria Pascual Parrilla, Murcia, Spain
| |
Collapse
|
11
|
Sharon CE, Grinberg S, Straker RJ, Mahmoud NN, Kelz RR, Miura JT, Karakousis GC. Trends in infectious complications after partial colectomy for colon cancer over a decade: A national cohort study. Surgery 2022; 172:1622-1628. [PMID: 36655827 DOI: 10.1016/j.surg.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/09/2022] [Accepted: 09/11/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program helps participating hospitals track and report surgical complications with the goal of improving patient care. We sought to determine whether postoperative infectious complications after elective colectomy for malignancy improved among participating centers over time. METHODS Patients with colon malignancies who underwent elective partial colectomy with primary anastomosis (categorized as low or non-low) were identified from the American College of Surgeons National Surgical Quality Improvement Program database (2011-2019). Thirty-day postoperative infectious complications analyzed by year included superficial, deep, and organ space surgical site infections, urinary tract infection, pneumonia, and sepsis. Trends in patient and treatment characteristics were investigated using log-linear regression along with their association with infectious outcomes. RESULTS Of the 78,827 patients identified, 51% were female, and the median age was 68. The majority (84%) underwent partial colectomy without a low anastomosis. There was a decrease in all infectious complications except for organ space infections which increased 35% overall from 2.0 to 2.7% (P = .037), driven by patients without a low anastomosis (1.9%-2.7%, P = .01). There was no change in most patient factors associated with organ space infections, except for a notable increase in American Society of Anesthesiologists class III and IV-V patients over time, both associated with organ space infections (P < .001; P = .002). CONCLUSION Infectious complications have decreased significantly overall after colectomy for colon cancer, whereas there has been an increase in organ space infection rates specifically. Although changing patient characteristics may contribute to this observed trend, further study is needed to better understand its etiology to help mitigate this complication.
Collapse
Affiliation(s)
- Cimarron E Sharon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Samuel Grinberg
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Richard J Straker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Najjia N Mahmoud
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John T Miura
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA. https://twitter.com/pennsurgery
| |
Collapse
|
12
|
Reducing Surgical Site Infection in Colorectal Surgery Using Mechanical Bowel Preparation and Oral Antibiotics: a Comparative Study in the Era of Enhanced Recovery After Surgery (ERAS) Protocol. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03626-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
13
|
Zarnescu EC, Zarnescu NO, Sanda N, Costea R. Risk Factors for Severe Postoperative Complications after Oncologic Right Colectomy: Unicenter Analysis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1598. [PMID: 36363555 PMCID: PMC9697206 DOI: 10.3390/medicina58111598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 08/30/2023]
Abstract
Background and Objectives: This study aimed to investigate the potential risk factors for severe postoperative complications after oncologic right colectomy. Materials and Methods: All consecutive patients with right colon cancer who underwent right colectomy in our department between 2016 and 2021 were retrospectively included in this study. The Clavien-Dindo grading system was used to evaluate postoperative complications. Univariate and multivariate logistic regression analyses were used to investigate risk factors for postoperative severe complications. Results: Of the 144 patients, there were 69 males and 75 females, with a median age of 69 (IQR 60-78). Postoperative morbidity and mortality rates were 41.7% (60 patients) and 11.1% (16 patients), respectively. The anastomotic leak rate was 5.3% (7 patients). Severe postoperative complications (Clavien-Dindo grades III-V) were present in 20 patients (13.9%). Univariate analysis showed the following as risk factors for postoperative severe complications: Charlson score, lack of mechanical bowel preparation, level of preoperative proteins, blood transfusions, and degree of urgency (elective/emergency right colectomy). In the logistic binary regression, the Charlson score (OR = 1.931, 95% CI = 1.077-3.463, p = 0.025) and preoperative protein level (OR = 0.049, 95% CI = 0.006-0.433, p = 0.007) were found to be independent risk factors for postoperative severe complications. Conclusions: Severe complications after oncologic right colectomy are associated with a low preoperative protein level and a higher Charlson comorbidity index.
Collapse
Affiliation(s)
- Eugenia Claudia Zarnescu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Narcis Octavian Zarnescu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Nicoleta Sanda
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Radu Costea
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| |
Collapse
|
14
|
Mechanical bowel preparation with or without oral antibiotics for rectal resection for cancer (REPCA trial): a study protocol for a multicenter randomized controlled trial. Tech Coloproctol 2022; 27:389-396. [PMID: 36151343 DOI: 10.1007/s10151-022-02706-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/11/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is still a lack of randomized trials assessing the clinical value of mechanical bowel preparation (MBP) and oral antibiotics (OA) before rectal surgery. Existing studies are inconsistent regarding OA. The aim of this study is to examine the role of MBP with or without OA (using Alfa Normix®) on postoperative complications in patients undergoing rectal resection for cancer. METHODS We are conducting a prospective multicenter randomized controlled trial comparing MBP (Moviprep®) with OA (Alfa Normix®) versus MBP alone in patients undergoing elective rectal resection for cancer. Patients with rectal or rectosigmoid cancer are randomized in a 1:1 allocation ratio. The primary endpoint is incisional surgical site infection (SSI) assessed within 30 days after surgery. Secondary endpoints are anastomotic leakage (AL), organ/space SSI, other postoperative complications, intraoperative complications, operation time, bowel preparation quality, bowel preparation adherence. Intention-to-treat and per protocol analyses will be performed. CONCLUSIONS The results of the REPCA trial will demonstrate whether MBP + OA is superior to MBP alone in rectal cancer surgery. This trial might influence current preoperative practice and improve postoperative outcomes.
Collapse
|
15
|
Gómez Sánchez J, Forneiro Pérez R, Zurita Saavedra M, de Castro Monedero P, González Puga C, Garde Lecumberri C, Mirón Pozo B. Oncologic colorectal surgical site infection: oral or not oral antibiotic preparation, that is the question. Int J Colorectal Dis 2022; 37:373-379. [PMID: 34854980 DOI: 10.1007/s00384-021-04074-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgical wound infection is the most frequent postoperative complication in abdominal surgery, especially at the colorectal level. The aim of this study is analysing the results of mechanical colon preparation combined with oral antibiotic versus mechanical colon preparation without antibiotic therapy in patients with colorectal cancer undergoing elective surgery. METHODS This retrospective cohort study had been developed from November 2017 to February 2020. We have included a total of 281 consecutive patients undergoing elective colon and rectal oncological surgeries by the same surgical group using laparoscopic and open approaches. Transanal minimally invasive surgery (TAMIS) and transanal total mesorectal excision (TaTME) approaches were excluded. Exposed patients undergoing colon and rectal cancer surgery received mechanical bowel preparation and oral antibiotics with three doses of neomycin 1 g and erythromycin 500 mg the day before surgery. RESULTS The primary outcome was reduction in surgical wound infection rates before and after starting the oral antibiotic therapy from 17 to 6% (p < 0.05). As a secondary analysis, we evaluated the anastomotic dehiscence rate, corresponding with a decrease from 12 to 3% (p < 0.05). CONCLUSION Mechanical bowel preparation combined with oral antibiotic therapy is still not unanimously carried out in all the medical hospitals. In this report, we show that mechanical bowel preparation in combination with oral antibiotic reduces the risk of surgical wound infection and anastomotic leakage in patients undergoing colon and rectal cancer surgery.
Collapse
Affiliation(s)
- Javier Gómez Sánchez
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Rocio Forneiro Pérez
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Marisol Zurita Saavedra
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Paola de Castro Monedero
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Cristina González Puga
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Carlos Garde Lecumberri
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Benito Mirón Pozo
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| |
Collapse
|
16
|
Gillespie BM, Harbeck E, Rattray M, Liang R, Walker R, Latimer S, Thalib L, Andersson AE, Griffin B, Ware R, Chaboyer W. Worldwide incidence of surgical site infections in general surgical patients: A systematic review and meta-analysis of 488,594 patients. Int J Surg 2021; 95:106136. [PMID: 34655800 DOI: 10.1016/j.ijsu.2021.106136] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/23/2021] [Accepted: 09/28/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Establishing worldwide incidence of general surgical site infections (SSI) is imperative to understand the extent of the condition to assist decision-makers to improve the planning and delivery of surgical care. This systematic review and meta-analysis aimed to estimate the worldwide incidence of SSI and identify associated factors in adult general surgical patients. MATERIALS AND METHODS A systematic review was undertaken using MEDLINE (Ovid), CINAHL (EBSCO), EMBASE (Elsevier) and the Cochrane Library to identify cross-sectional, cohort and observational studies reporting SSI incidence or prevalence. Studies of less than 50 participants were excluded. Data extraction and quality appraisal were undertaken independently by two review authors. The primary outcome was cumulative incidence of SSI occurring up to 30 days postoperative. The secondary outcome was the severity/depth of SSI. The I2 statistic was used to explore heterogeneity. Random effects models were used in the presence of substantial heterogeneity. Subgroup, meta-regression sensitivity analyses were used to explore the sources of heterogeneity. Publication bias was assessed using Hunter's plots and Egger's regression test. RESULTS Of 2091 publications retrieved, 62 studies were included. Of these, 57 were included in the meta-analysis across six anatomical locations with 488,594 patients. The pooled 30-day cumulative incidence of SSI was 11% (95% CI 10%-13%). No prevalence data were identified. SSI rates varied across anatomical location, surgical approach, and priority (i.e., planned, emergency). Multivariable meta-regression showed SSI is significantly associated with duration of surgery (estimate 1.01, 95% CI 1.00-1.02, P = .014). CONCLUSIONS and Relevance: 11 out of 100 general surgical patients are likely to develop an infection 30 days after surgery. Given the imperative to reduce the burden of harm caused by SSI, high-quality studies are warranted to better understand the patient and related risk factors associated with SSI.
Collapse
Affiliation(s)
- Brigid M Gillespie
- Griffith University Menzies Health Institute Queensland, National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Australia Gold Coast University Hospital, Gold Coast Health Nursing and Midwifery Education and Research Unit, Australia Griffith University Menzies Health Institute Queensland, Australia Gold Coast Hospital and Health Service, Department of Surgery, Australia Griffith University Faculty of Health, School of Nursing and Midwifery, Australia Princess Alexandra Hospital, Division of Surgery, QLD, Australia Gold Coast University Hospital, Patient Safety in Nursing, QLD, Australia Istanbul Aydın University, Department of Biostatistics, Faculty of Medicine, Istanbul, Turkey Sahlgrenska Academy, Institute of Health Care Sciences, Sweden Sahlgrenska University Hospital, Department of Orthopaedics, Sweden
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Lee JH, Ahn BK, Ryu J, Lee KH. Mechanical bowel preparation combined with oral antibiotics in colorectal cancer surgery: a nationwide population-based study. Int J Colorectal Dis 2021; 36:1929-1935. [PMID: 34089359 DOI: 10.1007/s00384-021-03967-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The guidelines for reducing surgical site infection in colorectal surgery recommend mechanical bowel preparation with oral antibiotics; however, this recommendation remains controversial. This study aimed to reveal the effect of oral antibiotics combined with mechanical bowel preparation in colorectal surgery. METHODS This study was a nationwide population-based retrospective study. Data between January 1, 2016, and December 31, 2018, from the Korean National Health Insurance Service database were analyzed. Patients who underwent elective colorectal cancer surgery were included. RESULTS A total of 20,740 patients were finally included, comprising 14,554 (70.2%) who underwent mechanical bowel preparation alone and 6186 (29.8%) who underwent mechanical bowel preparation with oral antibiotics. The mechanical bowel preparation alone group was older than the mechanical bowel preparation with oral antibiotics group (65.7 ± 11.9 vs. 64.7 ± 11.8 years, p < 0.001). Rectal cancer patients and patients who underwent open surgery were more likely to receive mechanical bowel preparation with oral antibiotics. Patients who underwent mechanical bowel preparation with oral antibiotics demonstrated lower surgical-site infection rate (2.9% vs. 9.4%, p < 0.001), shorter hospital stay (11.7 ± 5.5 vs. 13.5 ± 7.3 days, p < 0.001), and lower medical cost (US$7414 ± 2762 vs. US$7791 ± 3235, p < 0.001) than those who underwent mechanical bowel preparation alone. The 30-day readmission rates and mortality were not significantly different. CONCLUSIONS The use of mechanical bowel preparation with oral antibiotics reduces surgical site infection, hospital stay, and medical cost in colorectal cancer surgery.
Collapse
Affiliation(s)
- Jun Ho Lee
- Department of Surgery, College of Medicine, Hanyang University, 222-1 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Byung Kyu Ahn
- Department of Surgery, College of Medicine, Hanyang University, 222-1 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Jiin Ryu
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Seoul, Republic of Korea
| | - Kang Hong Lee
- Department of Surgery, College of Medicine, Hanyang University, 222-1 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea.
| |
Collapse
|
18
|
Koskenvuo L, Lehtonen T, Koskensalo S, Rasilainen S, Klintrup K, Ehrlich A, Pinta T, Scheinin T, Sallinen V. Mechanical and oral antibiotic bowel preparation versus no bowel preparation in right and left colectomy: subgroup analysis of MOBILE trial. BJS Open 2021; 5:6220257. [PMID: 33839753 PMCID: PMC8038265 DOI: 10.1093/bjsopen/zrab011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/15/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In retrospective series, mechanical and oral antibiotic bowel preparation (MOABP) has been reported to reduce surgical-site infections (SSIs) after colectomy compared with no bowel preparation (NBP). METHOD This was a subgroup analysis of a multicentre randomized trial that included patients scheduled for elective colectomy. The MOABP group underwent mechanical bowel preparation, and took 2 g neomycin and 2 g metronidazole orally during the day before surgery. The NBP group did not undergo bowel preparation. Patients were categorized according to the side of resection (right versus left colectomy), and these subgroups compared for postoperative outcomes. RESULTS Among 217 patients undergoing right colectomy (106 in MOABP and 111 in NBP group), SSI was detected in seven (7 per cent) and 10 (9 per cent) patients (odds ratio (OR) 0.71, 95 per cent c.i. 0.26 to 1.95; P = 0.510), anastomotic dehiscence in two (2 per cent) and two (2 per cent) patients (OR 1.05, 0.15 to 7.58; P = 1.000), and the mean(s.d.) Comprehensive Complication Index (CCI) score was 9.4(12.9) and 10.5(18.0) (mean difference -1.09; 95 per cent c.i. -5.29 to 3.11; P = 0.608) in the MOABP and NBP groups respectively. Among 164 patients undergoing left colectomy (84 in MOABP and 80 in NBP group), SSI was detected in five (6 per cent) and eight (10 per cent) patients (OR 0.57, 0.18 to 1.82; P = 0.338), anastomotic dehiscence in four (5 per cent) and five (6 per cent) patients (OR 0.75, 0.19 to 2.90; P = 0.742), and the CCI score was 10.2(13.1) and 6.5(11.0) (mean difference 3.68, -0.06 to 7.42; P = 0.053) in the MOABP and NBP groups respectively. CONCLUSIONS MOABP did not decrease the rate of SSI or complications in patients undergoing either right or left colectomy compared with NBP.
Collapse
Affiliation(s)
- L Koskenvuo
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - T Lehtonen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - S Koskensalo
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - S Rasilainen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - K Klintrup
- Department of Surgery, Surgical Research Unit, Medical Research Centre, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - A Ehrlich
- Department of Surgery, Central Hospital of Central Finland, Jyväskylä, Finland
| | - T Pinta
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - T Scheinin
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - V Sallinen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
19
|
Rakhit S, Geiger TM. Technical considerations for elective colectomy for diverticulitis. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2020.100801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
20
|
Liang Y, Xin W, Xi L, Fu H, Yang Y, Yang G, Li X. Role of mechanical and oral antibiotic bowel preparation in children with Hirschsprung's disease undergoing colostomy closure and pull-through. Transl Pediatr 2021; 10:153-159. [PMID: 33633947 PMCID: PMC7882283 DOI: 10.21037/tp-20-306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Mechanical and oral antibiotic bowel preparation (MOABP) has been performed routinely before colorectal surgery in children, but the necessity was questioned recently. We evaluated the utility of MOABP in children with Hirschsprung's disease (HSCR) undergoing colostomy closure and pull-through. METHODS The medical records of pediatric patients with HSCR who underwent colostomy closure and pull-through in a single center from January 2010 to January 2020 were reviewed. The use of MOABP was noted. The incidence of postoperative complications, duration of postoperative antibiotic therapy, total hospital cost and length-of-stay were compared between patients receiving MOABP and no bowel preparation (NBP). RESULTS A total of 64 patients were included in the study: 33 received MOABP and 31 had NBP. The respective postoperative complications in the MOABP and NBP groups were: intra-abdominal infection (18.2% vs. 29.0%), wound infection (9.1% vs. 16.1%), anastomotic leak (0 vs. 0), intestinal obstruction (6.1% vs. 0) and enterocolitis (3.03% vs. 12.90%). The duration of antibiotic therapy was 4.91±4.21 and 5.23±3.77 days (P=0.75) and hospitalization was 18.21±7.26 and 16.26±6.63 days (P=0.27) respectively. The total hospital cost in the MOABP group (4,720.14±1,858.89 USD) was higher than in the NBP group (3,749.06±2,009.97 USD) (P=0.049). CONCLUSIONS We did not find any clear benefit of MOABP in children with HSCR before colostomy closure and pull-through. However, a multicenter randomized controlled trial is needed to more definitely determine the best preoperative approach for children with HSCR.
Collapse
Affiliation(s)
- Yuanyuan Liang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing, Sichuan University, Chengdu, China
| | - Wenqiong Xin
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing, Sichuan University, Chengdu, China
| | - Ling Xi
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing, Sichuan University, Chengdu, China
| | - Huan Fu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing, Sichuan University, Chengdu, China
| | - Yang Yang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing, Sichuan University, Chengdu, China
| | - Gang Yang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoling Li
- West China School of Nursing, Sichuan University, Chengdu, China
| |
Collapse
|
21
|
Rollins KE, Lobo DN. The Controversies of Mechanical Bowel and Oral Antibiotic Preparation in Elective Colorectal Surgery. Ann Surg 2021; 273:e13-e15. [PMID: 33064393 DOI: 10.1097/sla.0000000000003985] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Katie E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| |
Collapse
|
22
|
McKenna NP, Bews KA, Colibaseanu DT, Mathis KL, Nelson H, Habermann EB. The intersection of tumor location and combined bowel preparation: Utilization differs but anastomotic leak risk reduction does not. J Surg Oncol 2020; 123:261-270. [PMID: 33002190 DOI: 10.1002/jso.26224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/16/2020] [Accepted: 09/05/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE Whether bowel preparation utilization rates or effectiveness varies based on tumor location is unknown. METHODS The 2012-2016 American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted participant user file was queried for patients undergoing elective colorectal resection for cancer. Bowel preparation was classified as combined, mechanical bowel preparation alone, oral antibiotic alone, or none. Cochran-Armitage tests were used for trend analysis. Multivariable analyses stratified by tumor location were performed for the outcome of anastomotic leak. An additional multivariable model including all tumor locations assessed for interaction between bowel preparation and tumor location on an anastomotic leak. RESULTS A total of 29,739 operations were included and the anastomotic leak rate was 1.9% with combined preparation versus 4.0% without preparation. Combined bowel preparation utilization increased over time as tumor location became more distal (both p < .0001). However, the adjusted effect of combined bowel preparation on anastomotic leak risk reduction did not differ by individual tumor location or across all tumor locations (p = .43 for interaction). CONCLUSION Though the utilization rate of combined bowel preparation increased as tumor location became more distal, its risk-reducing effect remained similar. Quality improvement initiatives should focus on increased utilization of combined bowel preparation with an emphasis on tumors in the ascending colon.
Collapse
Affiliation(s)
- Nicholas P McKenna
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Health Care Policy and Research, The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Katherine A Bews
- Division of Health Care Policy and Research, The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Dorin T Colibaseanu
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi Nelson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Health Care Policy and Research, The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
23
|
Franke AJ, Skelton WP, George TJ, Iqbal A. A Comprehensive Review of Randomized Clinical Trials Shaping the Landscape of Rectal Cancer Therapy. Clin Colorectal Cancer 2020; 20:1-19. [PMID: 32863179 DOI: 10.1016/j.clcc.2020.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 12/31/2022]
Abstract
Colorectal carcinoma is the second leading cause of cancer-related deaths in the United States, with rectal cancer accounting for approximately one third of newly diagnosed cases. Surgery remains the cornerstone of curative therapy, with total mesorectal excision being the standard of care. Although minimally invasive procedures might be appropriate for a subset of patients with early-stage, superficial tumors, the standard of care for medically operable patients with nonmetastatic rectal cancer includes a comprehensive multimodality approach of neoadjuvant chemoradiotherapy, surgery with total mesorectal excision, and systemic chemotherapy. However, the morbidity and mortality related to both local and distant organ relapse have remained challenging. In the present review, we have discussed the trial-level evidence that has shaped the current clinical practice patterns in the treatment of curable, nonmetastatic rectal cancer. In addition, we have discussed the anticipated results of ongoing clinical trials and outlined pragmatic opportunities for future investigation to optimize the current status quo and, hopefully, provide prospective validation of novel approaches in the treatment of rectal cancer.
Collapse
Affiliation(s)
- Aaron J Franke
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, FL
| | - William Paul Skelton
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, FL
| | - Thomas J George
- Department of Medicine, Division of Hematology and Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Atif Iqbal
- Section of Colorectal Surgery, Department of Surgery, Baylor College of Medicine, Houston, TX.
| |
Collapse
|
24
|
Blanc MC, Slim K, Beyer-Berjot L. Best practices in bowel preparation for colorectal surgery: a 2020 overview. Expert Rev Gastroenterol Hepatol 2020; 14:681-688. [PMID: 32476518 DOI: 10.1080/17474124.2020.1775581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Cohort studies have recently initiated a paradigm shift in the field of preoperative bowel preparation. Indeed, the adjunction of oral antibiotics (OAB) to mechanical bowel preparation (MBP) is now the gold standard for the American guidelines. However, this strategy is highly controverted. AREAS COVERED This review was an up-to-date analysis of literature on bowel preparation. We conducted a systematic review for randomized controlled trials (RCTs) and meta-analyses published since 2009. A non-exhaustive overview of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) cohort studies and the international guidelines was also given, and future leads were discussed. EXPERT OPINION The methodology of the ACS NSQIP studies did not allow a strong conclusion in favor of the association MBP+OAB. Besides, guidelines were not univocal, with non-American guidelines promoting no preparation at all. RCTs favored OAB alone: indeed, MBP+OAB showed no benefits in terms of surgical site infection (SSI) except when compared to MBP alone, while OAB alone seemed superior to no preparation. Likewise, the meta-analyses also favored OAB alone in terms of overall SSI and organ space infection. Large RCTs are currently running and may change these conclusions. Finally, microbiota is a future lead for personalized OAB.
Collapse
Affiliation(s)
- Marie-Caroline Blanc
- Department of Visceral Surgery, CHU de Marseille, Hôpital Nord , Marseille, France
| | - Karem Slim
- Department of Digestive Surgery, CHU Clermont-Ferrand , Clermont-Ferrand, France
| | - Laura Beyer-Berjot
- Department of Visceral Surgery, CHU de Marseille, Hôpital Nord , Marseille, France
| |
Collapse
|
25
|
Espin Basany E, Solís-Peña A, Pellino G, Kreisler E, Fraccalvieri D, Muinelo-Lorenzo M, Maseda-Díaz O, García-González JM, Santamaría-Olabarrieta M, Codina-Cazador A, Biondo S. Preoperative oral antibiotics and surgical-site infections in colon surgery (ORALEV): a multicentre, single-blind, pragmatic, randomised controlled trial. Lancet Gastroenterol Hepatol 2020; 5:729-738. [DOI: 10.1016/s2468-1253(20)30075-3] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/02/2020] [Accepted: 03/02/2020] [Indexed: 12/23/2022]
|
26
|
Kalogera E, Van Houten HK, Sangaralingham LR, Borah BJ, Dowdy SC. Use of bowel preparation does not reduce postoperative infectious morbidity following minimally invasive or open hysterectomies. Am J Obstet Gynecol 2020; 223:231.e1-231.e12. [PMID: 32112733 DOI: 10.1016/j.ajog.2020.02.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/09/2020] [Accepted: 02/18/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Literature on the use of bowel preparation in gynecologic surgery is scarce and limited to minimally invasive gynecologic surgery. The decision on the use of bowel preparation before benign or malignant hysterectomies is mostly driven by extrapolating data from the colorectal literature. OBJECTIVE Bowel preparation is a controversial element within enhanced recovery protocols, and literature investigating its efficacy in gynecologic surgery is scarce. Our aim was to determine if mechanical bowel preparation alone, oral antibiotics alone, or a combination are associated with decreased rates of surgical site infections or anastomotic leaks compared to no bowel preparation following benign or malignant hysterectomy. STUDY DESIGN We identified women who underwent hysterectomy between January 2006 and July 2017 using OptumLabs, a large US commercial health plan database. Inverse propensity score weighting was used separately for benign and malignant groups to balance baseline characteristics. Primary outcomes of 30-day surgical site infection, anastomotic leaks, and major morbidity were assessed using multivariate logistic regression that adjusted for race, census region, household income, diabetes, and other unbalanced variables following propensity score weighting. RESULTS A total of 224,687 hysterectomies (benign, 186,148; malignant, 38,539) were identified. Median age was 45 years for the benign and 54 years for the malignant cohort. Surgical approach was as follows: benign: laparoscopic/robotic, 27.2%; laparotomy, 32.6%; vaginal, 40.2%; malignant: laparoscopic/robotic, 28.8%; laparotomy, 47.7%; vaginal, 23.5%. Bowel resection was performed in 0.4% of the benign and 2.8% of the malignant cohort. Type of bowel preparation was as follows: benign: none, 93.8%; mechanical bowel preparation only, 4.6%; oral antibiotics only, 1.1%; mechanical bowel preparation with oral antibiotics, 0.5%; malignant: none, 87.2%; mechanical bowel preparation only, 9.6%; oral antibiotics only, 1.8%; mechanical bowel preparation with oral antibiotics, 1.4%. Use of bowel preparation did not decrease rates of surgical site infections, anastomotic leaks, or major morbidity following benign or malignant hysterectomy. Among malignant abdominal hysterectomies, there was no difference in the rates of infectious morbidity between mechanical bowel preparation alone, oral antibiotics alone, or mechanical bowel preparation with oral antibiotics, compared to no preparation. CONCLUSION Bowel preparation does not protect against surgical site infections or major morbidity following benign or malignant hysterectomy, regardless of surgical approach, and may be safely omitted.
Collapse
Affiliation(s)
| | - Holy K Van Houten
- Department of Health Sciences, Division of Health Care Policy and Research & Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; OptumLabs, Cambridge, MA
| | - Lindsey R Sangaralingham
- Department of Health Sciences, Division of Health Care Policy and Research & Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; OptumLabs, Cambridge, MA
| | - Bijan J Borah
- Department of Health Sciences, Division of Health Care Policy and Research & Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN.
| |
Collapse
|
27
|
Robotic treatment of bowel endometriosis. Best Pract Res Clin Obstet Gynaecol 2020; 71:129-143. [PMID: 32684433 DOI: 10.1016/j.bpobgyn.2020.05.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 12/18/2022]
Abstract
Endometriosis describes a condition with the presence of ectopic endometrial glands and stroma outside the endometrial cavity that affects up to 15% of reproductive-aged women. Of women affected with endometriosis, 3.8-37% will have endometriosis involving the bowel, primarily the rectosigmoid colon. While medical management is often recommended as a first-line therapy, it is not curative, and surgery is often required as an adjunct for the management of symptoms. Minimally invasive surgery has become the standard of care for managing these patients. The use of robotic-assisted laparoscopy offers benefits that may allow surgeons to perform these challenging surgical cases using a minimally invasive technique. For lesions that affect the colon, there are three primary techniques used for removal which include: 1) rectal shaving, 2) discoid excision and 3) segmental resection. The decision to pursue one approach over another is largely dependent on the number of lesions present, a lesion's size and depth of invasion as well as the involved circumference of the bowel. The available evidence of using robotic-assisted laparoscopy in cases of bowel endometriosis is limited in the literature. In this review, we will summarize the role of robotic-assisted laparoscopy in the management of bowel endometriosis.
Collapse
|
28
|
Rollins KE. Bowel preparation in elective colorectal surgery: is mechanical bowel preparation necessary? Lancet Gastroenterol Hepatol 2020; 5:712-713. [PMID: 32673601 DOI: 10.1016/s2468-1253(20)30193-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Katie E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK.
| |
Collapse
|
29
|
Jago CA, Nguyen DB, Flaxman TE, Singh SS. Bowel surgery for endometriosis: A practical look at short- and long-term complications. Best Pract Res Clin Obstet Gynaecol 2020; 71:144-160. [PMID: 32680784 DOI: 10.1016/j.bpobgyn.2020.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/04/2020] [Indexed: 02/06/2023]
Abstract
Endometriosis involving the bowel requires a thorough evaluation prior to deciding upon surgical treatment. Patient symptoms, treatment goals, extent and location of disease, surgeon experience, and anticipated risks all play a part in the preoperative decision-making process. Short- and long-term complications after bowel surgery for endometriosis are the focus of this article. Unfortunately, the literature to date has inherent limitations that prevent generalizability. Most studies are retrospective or prospective single-center case series. Publication bias is unavoidable with mainly large volume experts sharing their experience. As a result, there is a need for high-quality prospective studies that standardize inclusion criteria and outcome measures among various centers with an aim to present long-term outcomes. In the meantime, care for those with endometriosis involving the bowel requires a thorough preoperative plan to minimize risks and a need for early diagnosis and management of complications unique to bowel surgery.
Collapse
Affiliation(s)
- Caitlin Anne Jago
- Minimally Invasive Gynecology Research Group, Department of Ob/Gyn and Newborn Care, University of Ottawa & the Ottawa Hospital, 501 Smyth Rd, K1H 8L6, Ottawa ON Canada
| | - Dong Bach Nguyen
- Minimally Invasive Gynecology Research Group, Department of Ob/Gyn and Newborn Care, University of Ottawa & the Ottawa Hospital, 501 Smyth Rd, K1H 8L6, Ottawa ON Canada
| | - Teresa E Flaxman
- Minimally Invasive Gynecology Research Group, Department of Ob/Gyn and Newborn Care, University of Ottawa & the Ottawa Hospital, 501 Smyth Rd, K1H 8L6, Ottawa ON Canada; Ottawa Hospital Research Institute, Department of Clinical Epidemiology, 1053 Carling Ave, K1Y 4E9, Ottawa ON Canada
| | - Sukhbir S Singh
- Minimally Invasive Gynecology Research Group, Department of Ob/Gyn and Newborn Care, University of Ottawa & the Ottawa Hospital, 501 Smyth Rd, K1H 8L6, Ottawa ON Canada; Ottawa Hospital Research Institute, Department of Clinical Epidemiology, 1053 Carling Ave, K1Y 4E9, Ottawa ON Canada.
| |
Collapse
|
30
|
Mulder T, Kluytmans-van den Bergh M, Vlaminckx B, Roos D, de Smet AM, de Vos Tot Nederveen Cappel R, Verheijen P, Brandt A, Smits A, van der Vorm E, Bathoorn E, van Etten B, Veenemans J, Weersink A, Vos M, van 't Veer N, Nikolakopoulos S, Bonten M, Kluytmans J. Prevention of severe infectious complications after colorectal surgery using oral non-absorbable antimicrobial prophylaxis: results of a multicenter randomized placebo-controlled clinical trial. Antimicrob Resist Infect Control 2020; 9:84. [PMID: 32539786 PMCID: PMC7294517 DOI: 10.1186/s13756-020-00745-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/29/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are common complications after colorectal surgery. Oral non-absorbable antibiotic prophylaxis (OAP) can be administered preoperatively to reduce the risk of SSIs. Its efficacy without simultaneous mechanical cleaning is unknown. METHODS The Precaution trial was a double-blind, placebo-controlled randomized clinical trial conducted in six Dutch hospitals. Adult patients who underwent elective colorectal surgery were randomized to receive either a three-day course of preoperative OAP with tobramycin and colistin or placebo. The primary composite endpoint was the incidence of deep SSI or mortality within 30 days after surgery. Secondary endpoints included both infectious and non-infectious complications at 30 days and six months after surgery. RESULTS The study was prematurely ended due to the loss of clinical equipoise. At that time, 39 patients had been randomized to active OAP and 39 to placebo, which reflected 8.1% of the initially pursued sample size. Nine (11.5%) patients developed the primary outcome, of whom four had been randomized to OAP (4/39; 10.3%) and five to placebo (5/39; 12.8%). This corresponds to a risk ratio in the intention-to-treat analysis of 0.80 (95% confidence interval (CI) 0.23-2.78). In the per-protocol analysis, the relative risk was 0.64 (95% CI 0.12-3.46). CONCLUSIONS Observational data emerging during the study provided new evidence for the effectiveness of OAP that changed both the clinical and medical ethical landscape for infection prevention in colorectal surgery. We therefore consider it unethical to continue randomizing patients to placebo. We recommend the implementation of OAP in clinical practice and continuing monitoring of infection rates and antibiotic susceptibilities. TRIAL REGISTRATION The PreCaution trial is registered in the Netherlands Trial Register under NL5932 (previously: NTR6113) as well as in the EudraCT register under 2015-005736-17.
Collapse
Affiliation(s)
- Tessa Mulder
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marjolein Kluytmans-van den Bergh
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Amphia Academy Infectious Disease Foundation, Amphia Hospital, Breda, The Netherlands
- Department of Infection Control, Amphia Hospital, Breda, The Netherlands
| | - Bart Vlaminckx
- Department of Medical Microbiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Anne Marie de Smet
- Department of Intensive Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Paul Verheijen
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - Alexandra Brandt
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Anke Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Eric van der Vorm
- Department of Medical Microbiology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Erik Bathoorn
- Department of Medical Microbiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Boudewijn van Etten
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jacobien Veenemans
- Department of Medical Microbiology, Admiraal de Ruyter Hospital, Goes, the Netherlands
| | - Annemarie Weersink
- Department of Medical Microbiology, Meander Medical Center, Amersfoort, The Netherlands
| | - Margreet Vos
- Department of Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nils van 't Veer
- Department of Clinical Pharmacy, Amphia Hospital, Breda, The Netherlands
| | - Stavros Nikolakopoulos
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Medical Microbiology, Utrecht University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Jan Kluytmans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
- Department of Infection Control, Amphia Hospital, Breda, The Netherlands.
| |
Collapse
|
31
|
Duff SE, Battersby CLF, Davies RJ, Hancock L, Pipe J, Buczacki S, Kinross J, Acheson AG, Walsh CJ. The use of oral antibiotics and mechanical bowel preparation in elective colorectal resection for the reduction of surgical site infection. Colorectal Dis 2020; 22:364-372. [PMID: 32061026 PMCID: PMC8247270 DOI: 10.1111/codi.14982] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 12/24/2019] [Indexed: 12/12/2022]
Affiliation(s)
- S. E. Duff
- Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
| | | | - R. J. Davies
- Cambridge Colorectal UnitAddenbrookes HospitalCambridge University NHS Foundation TrustCambridgeUK
| | - L. Hancock
- Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
| | - J. Pipe
- Patient Liaison Group ACPGBISheffieldUK
| | - S. Buczacki
- Cambridge Colorectal UnitAddenbrookes HospitalCambridge University NHS Foundation TrustCambridgeUK
| | - J. Kinross
- Department of Surgery and CancerSt Mary's HospitalImperial CollegeLondonUK
| | - A. G. Acheson
- Gastrointestinal SurgeryNottingham Digestive Diseases CentreNational Institute for Health Research (NIHR)Biomedical Research CentreNottingham University Hospitals NHS TrustQueen’s Medical CentreUniversity of NottinghamNottinghamUK
| | - C. J. Walsh
- Wirral University Teaching Hospitals NHS Foundation TrustWirralUK
| |
Collapse
|
32
|
Rink AD, Kienle P, Aigner F, Ulrich A. How to reduce anastomotic leakage in colorectal surgery-report from German expert meeting. Langenbecks Arch Surg 2020; 405:223-232. [PMID: 32189067 DOI: 10.1007/s00423-020-01864-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 03/05/2020] [Indexed: 01/16/2023]
Abstract
AIMS Anastomotic leakage is one of the most worrisome complications in colorectal surgery. An expert meeting was organized to discuss and find a consensus on various aspects of the surgical management of colorectal disease with a possible impact on anastomotic leakage. METHODS A three-step Delphi-method was used to find consensus recommendations. RESULTS Strong consensus was achieved for the use of mechanical bowel preparation and oral antibiotics prior to colorectal resections, the abundance of non-selective NSAIDs, the preoperative treatment of severe iron deficiency anemia, and for attempting to improve the patients' general performance in the case of frailty. Concerning technical aspects of rectal resection, there was a strong consensus in regard to routinely mobilizing the splenic flexure, to dividing the inferior mesenteric vein, and to using air leak tests to check anastomotic integrity. There was also a strong consensus on not to oversew the stapled anastomoses routinely, to use protective ileostomies for low rectal and intersphincteric, but not for high-rectal anastomoses. Furthermore, a consensus was reached in regard to using CT-scans with rectal contrast enema to evaluate suspected anastomotic leakage as well as measuring C-reactive protein routinely to monitor the postoperative course after colorectal resections. No consensus was found concerning the indication and technique for testing bowel perfusion, the routine use of endoscopy to check the integrity of the anastomosis, the placement of transanal drains for rectal anastomoses and the management of anastomotic leakage with peritonitis. CONCLUSION Consensus could be found for several practice details in the perioperative management in colorectal surgery that might have an influence on anastomotic leakage.
Collapse
Affiliation(s)
- Andreas D Rink
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Leverkusen gGmbH, Am Gesundheitspark 11, 51375, Leverkusen, Germany.
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany.
| | - Peter Kienle
- Klinik für Allgemein- und Viszeralchirurgie, Theresienkrankenhaus und St. Hedwig-Klinik GmbH, Mannheim, Germany
| | - Felix Aigner
- Chirurgische Klinik Campus Charité Mitte/Campus Virchow, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexis Ulrich
- Chirurgische Klinik I, Rheinland Klinikum GmbH, Lukaskrankenhaus Neuss, Neuss, Germany
| |
Collapse
|
33
|
Koskenvuo L, Lehtonen T, Koskensalo S, Rasilainen S, Klintrup K, Ehrlich A, Pinta T, Scheinin T, Sallinen V. Mechanical and oral antibiotic bowel preparation versus no bowel preparation for elective colectomy (MOBILE): a multicentre, randomised, parallel, single-blinded trial. Lancet 2019; 394:840-848. [PMID: 31402112 DOI: 10.1016/s0140-6736(19)31269-3] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/16/2019] [Accepted: 05/21/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Decreased surgical site infections (SSIs) and morbidity have been reported with mechanical and oral antibiotic bowel preparation (MOABP) compared with no bowel preparation (NBP) in colonic surgery. Several societies have recommended routine use of MOABP in patients undergoing colon resection on the basis of these data. Our aim was to investigate this recommendation in a prospective randomised context. METHODS In this multicentre, parallel, single-blinded trial, patients undergoing colon resection were randomly assigned (1:1) to either MOABP or NBP in four hospitals in Finland, using a web-based randomisation technique. Randomly varying block sizes (four, six, and eight) were used for randomisation, and stratification was done according to centre. The recruiters, treating physicians, operating surgeons, data collectors, and analysts were masked to the allocated treatment. Key exclusion criteria were need for emergency surgery; bowel obstruction; colonoscopy planned during surgery; allergy to polyethylene glycol, neomycin, or metronidazole; and age younger than 18 years or older than 95 years. Study nurses opened numbered opaque envelopes containing the patient allocated group, and instructed the patients according to the allocation group to either prepare the bowel, or not prepare the bowel. Patients allocated to MOABP prepared their bowel by drinking 2 L of polyethylene glycol and 1 L of clear fluid before 6 pm on the day before surgery and took 2 g of neomycin orally at 7 pm and 2 g of metronidazole orally at 11 pm the day before surgery. The primary outcome was SSI within 30 days after surgery, analysed in the modified intention-to-treat population (all patients who were randomly allocated to and underwent elective colon resection with an anastomosis) along with safety analyses. The trial is registered with ClinicalTrials.gov, NCT02652637, and EudraCT, 2015-004559-38, and is closed to new participants. FINDINGS Between March 17, 2016, and Aug 20, 2018, 738 patients were assessed for eligibility. Of the 417 patients who were randomised (209 to MOABP and 208 to NBP), 13 in the MOABP group and eight in the NBP were excluded before undergoing colonic resection; therefore, the modified intention-to-treat analysis included 396 patients (196 for MOABP and 200 for NBP). SSI was detected in 13 (7%) of 196 patients randomised to MOABP, and in 21 (11%) of 200 patients randomised to NBP (odds ratio 1·65, 95% CI 0·80-3·40; p=0·17). Anastomotic dehiscence was reported in 7 (4%) of 196 patients in the MOABP group and in 8 (4%) of 200 in the NBP group, and reoperations were necessary in 16 (8%) of 196 compared with 13 (7%) of 200 patients. Two patients died in the NBP group and none in the MOABP group within 30 days. INTERPRETATION MOABP does not reduce SSIs or the overall morbidity of colon surgery compared with NBP. We therefore propose that the current recommendations of using MOABP for colectomies to reduce SSIs or morbidity should be reconsidered. FUNDING Vatsatautien Tutkimussäätiö Foundation, Mary and Georg Ehrnrooth's Foundation, and Helsinki University Hospital research funds.
Collapse
Affiliation(s)
- Laura Koskenvuo
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Taru Lehtonen
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Selja Koskensalo
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Suvi Rasilainen
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Kai Klintrup
- Department of Surgery, Surgical Research Unit, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Anu Ehrlich
- Department of Surgery, Central Hospital of Central Finland, Jyväskylä, Finland
| | - Tarja Pinta
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Tom Scheinin
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| |
Collapse
|
34
|
Mulder T, Kluytmans JA. Oral antibiotics prior to colorectal surgery: Do they have to be combined with mechanical bowel preparation? Infect Control Hosp Epidemiol 2019; 40:922-927. [PMID: 31196253 PMCID: PMC6669987 DOI: 10.1017/ice.2019.157] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/30/2019] [Accepted: 05/04/2019] [Indexed: 12/14/2022]
Abstract
To reduce the of risk infection after colorectal surgery, oral antibiotic preparation (OAP) and mechanical bowel preparation (MBP) can be applied. Whether OAP can be used without MBP is unclear. A meta-analysis of observational studies demonstrated comparable effectiveness of OAP with and without MBP regarding SSI risk.
Collapse
Affiliation(s)
- Tessa Mulder
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan A.J.W. Kluytmans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Infection Control, Amphia Hospital, Breda, The Netherlands
| |
Collapse
|
35
|
Cortez AR, Kassam AF, Levinsky NC, Jung AD, Daly MC, Shah SA, Rafferty JF, Paquette IM. Enhanced recovery protocol improves postoperative outcomes and minimizes narcotic use following resection for colon and rectal cancer. Surg Open Sci 2019; 1:74-79. [PMID: 32754696 PMCID: PMC7391893 DOI: 10.1016/j.sopen.2019.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/20/2019] [Accepted: 05/22/2019] [Indexed: 12/12/2022] Open
Abstract
Background Enhanced recovery protocols are associated with improved recovery. However, data on outcomes following the implementation of an enhanced recovery protocol in colorectal cancer are limited. We set out to study the postoperative outcomes, opioid use patterns, and cost impact for patients undergoing colon or rectal resection for cancer. Methods A retrospective review of all elective colorectal cancer resections from January 2015 to June 2018 at a single institution was performed. Patient demographics, operative details, and postoperative outcomes were collected. Colon and rectal patients were studied separately, with comparison of patients before and after the implementation of an enhanced recovery protocol. Results One hundred ninety-two patients underwent elective colorectal resection for cancer. In January 2016, an enhanced recovery protocol was implemented for all elective resections - 71 patients (33 colon and 38 rectal) underwent surgery before implementation and 121 patients (56 colon and 65 rectal) underwent surgery after implementation of the enhanced recovery protocol. There were no differences with regard to age, gender, or body mass index before or after implementation (all P > .05). For both colon and rectal cancer patients, the enhanced recovery protocol reduced time to regular diet (both P < .05) and length of stay (colon: 3 vs 4 days; rectal: 4 vs 6 days; both P < .01). Enhanced recovery protocol patients also consumed fewer total narcotics (colon: 44 vs 184 morphine milligram equivalents, P < .01; rectal: 121 vs 393 morphine milligram equivalents, P < .01). Conclusions Enhanced recovery protocol use reduced length of stay and narcotic use with similar total costs and no difference in 30-day complications for both colon and rectal cancer resections.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Ian M. Paquette
- Corresponding author at: Department of Surgery, University of Cincinnati College of Medicine, 2123 Auburn Ave #524, Cincinnati, OH 45219.
| |
Collapse
|
36
|
Rollins KE, Javanmard-Emamghissi H, Acheson AG, Lobo DN. The Role of Oral Antibiotic Preparation in Elective Colorectal Surgery: A Meta-analysis. Ann Surg 2019; 270:43-58. [PMID: 30570543 PMCID: PMC6570620 DOI: 10.1097/sla.0000000000003145] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To compare the impact of the use of oral antibiotics (OAB) with or without mechanical bowel preparation (MBP) on outcome in elective colorectal surgery. SUMMARY BACKGROUND DATA Meta-analyses have demonstrated that MBP does not impact upon postoperative morbidity or mortality, and as such it should not be prescribed routinely. However, recent evidence from large retrospective cohort and database studies has suggested that there may be a role for combined OAB and MBP, or OAB alone in the prevention of surgical site infection (SSI). METHODS A meta-analysis of randomized controlled trials and cohort studies including adult patients undergoing elective colorectal surgery, receiving OAB with or without MBP was performed. The outcome measures examined were SSI, anastomotic leak, 30-day mortality, overall morbidity, development of ileus, reoperation and Clostridium difficile infection. RESULTS A total of 40 studies with 69,517 patients (28 randomized controlled trials, n = 6437 and 12 cohort studies, n = 63,080) were included. The combination of MBP+OAB versus MBP alone was associated with a significant reduction in SSI [risk ratio (RR) 0.51, 95% confidence interval (CI) 0.46-0.56, P < 0.00001, I = 13%], anastomotic leak (RR 0.62, 95% CI 0.55-0.70, P < 0.00001, I = 0%), 30-day mortality (RR 0.58, 95% CI 0.44-0.76, P < 0.0001, I = 0%), overall morbidity (RR 0.67, 95% CI 0.63-0.71, P < 0.00001, I = 0%), and development of ileus (RR 0.72, 95% CI 0.52-0.98, P = 0.04, I = 36%), with no difference in Clostridium difficile infection rates. When a combination of MBP+OAB was compared with OAB alone, no significant difference was seen in SSI or anastomotic leak rates, but there was a significant reduction in 30-day mortality, and incidence of postoperative ileus with the combination. There is minimal literature available on the comparison between combined MBP+OAB versus no preparation, OAB alone versus no preparation, and OAB versus MBP. CONCLUSIONS Current evidence suggests a potentially significant role for OAB preparation, either in combination with MBP or alone, in the prevention of postoperative complications in elective colorectal surgery. Further high-quality evidence is required to differentiate between the benefits of combined MBP+OAB or OAB alone.
Collapse
Affiliation(s)
- Katie E. Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Hannah Javanmard-Emamghissi
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Austin G. Acheson
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
- MRC/ARUK Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| |
Collapse
|
37
|
Ioannidis A, Zoikas A, Wexner SD. Current Evidence of Combination of Oral Antibiotics and Mechanical Bowel Preparation in Elective Colorectal Surgery and Their Impact on Anastomotic Leak. Surg Innov 2019; 27:101-102. [PMID: 31140378 DOI: 10.1177/1553350619851672] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Anastomotic leak represents a potentially catastrophic complication following colorectal surgery. Preoperatively, bowel preparation has a significant role in anastomotic leak prevention, but the optimal method remains unclear. Recently, numerous studies have supported combined mechanical bowel preparation and oral antibiotics prior to elective colorectal operations. Based on the plethora of recent data, we hope that surgeons will routinely use a combination of oral antibiotics and mechanical bowel preparation prior to elective colorectal resections.
Collapse
|
38
|
Carpenter KL, Breckler FD, Gray BW. Role of Mechanical Bowel Preparation and Perioperative Antibiotics in Pediatric Pull-Through Procedures. J Surg Res 2019; 241:222-227. [PMID: 31029932 DOI: 10.1016/j.jss.2019.03.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 02/21/2019] [Accepted: 03/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND There are no clear guidelines for the use of mechanical bowel preparation and postoperative antibiotics in children undergoing elective colorectal pull-through surgery. The objective of this study was to determine whether preoperative bowel preparation administration or duration of postoperative antibiotics impacted the rate of complications after elective pediatric pull-through surgery. MATERIALS AND METHODS Patients aged <18 y who underwent a pull-through procedure between 2011 and 2017 were retrospectively identified. Patient data included diagnosis, procedure, administration of mechanical bowel preparation, and duration of perioperative intravenous (IV) antibiotics. Outcomes of interest included surgical site infections and anastomotic complications. RESULTS A total of 180 patients met inclusion criteria, of which 47.2% received mechanical bowel preparation. The combined rate of infectious and anastomotic complications was 12.2%. There was no significant difference in combined complication rate among those receiving bowel preparation compared with those who did not (14.1% versus 10.5%, P = 0.46). Administration of bowel preparation in the perineal anoplasty subgroup was associated with higher rates of wound infection (33.3% versus 3.3%, P = 0.05). One hundred five patients (58.3%) received perioperative IV antibiotics for ≤24 h. This group had similar rates of complications (13.3%) compared with those receiving IV antibiotics for longer than 24 h (11.6%, P = 0.74). CONCLUSIONS Although mechanical bowel preparation did not affect the overall complication rate for pull-through procedures, it was associated with more wound infections in those undergoing perineal anoplasty. Duration of postoperative IV antibiotics was not significantly associated with the rate of wound and anastomotic complications.
Collapse
Affiliation(s)
- Kyle L Carpenter
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Francine D Breckler
- Department of Pharmacy and Section of Pediatric Surgery, Riley Hospital for Children, Indianapolis, Indiana
| | - Brian W Gray
- Section of Pediatric Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana.
| |
Collapse
|
39
|
Eichelmann AK, Pascher A. [Preoperative bowel conditioning]. Chirurg 2019; 90:537-541. [PMID: 30976891 DOI: 10.1007/s00104-019-0957-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Gastrointestinal surgery is still associated with a relevant morbidity with the intestinal microbiome being of high importance in the pathogenesis of infectious complications. Various approaches, such as mechanical bowel preparation (MBP) with or without administration of oral antibiotics, fasting or dietary supplements aim at modulating the intestinal flora. OBJECTIVE This review summarizes the current literature pertinent to the influence of preoperative bowel conditioning on postoperative morbidity. MATERIAL AND METHODS A literature search was performed using the mentioned keywords with a focus on recent meta-analyses. RESULTS AND CONCLUSION Bowel conditioning reduces postoperative infectious complications. Promising approaches are MBP plus administration of oral antibiotics, dietary supplements aiming at stabilization of the intestinal flora as well as the screening for and equilibration of malnutrition. The use of MBP as monotherapy without antibiotics should no longer be considered part of the clinical routine.
Collapse
Affiliation(s)
- A-K Eichelmann
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
| | - A Pascher
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland.
| |
Collapse
|
40
|
Battersby C, Battersby N, Slade D, Soop M, Walsh C. Preoperative mechanical and oral antibiotic bowel preparation to reduce infectious complications of colorectal surgery – the need for updated guidelines. J Hosp Infect 2019; 101:295-299. [DOI: 10.1016/j.jhin.2018.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 12/14/2018] [Indexed: 12/17/2022]
|
41
|
Beyer-Berjot L, Slim K. Colorectal surgery and preoperative bowel preparation: aren't we drawing hasty conclusions? Colorectal Dis 2018; 20:955-958. [PMID: 30199608 DOI: 10.1111/codi.14415] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/30/2018] [Indexed: 12/27/2022]
Affiliation(s)
- L Beyer-Berjot
- Department of Digestive Surgery, APHM, Hôpital Nord, Aix-Marseille University, Marseille, France.,Francophone Group for Enhanced Recovery After Surgery (GRACE), Beaumont, France
| | - K Slim
- Francophone Group for Enhanced Recovery After Surgery (GRACE), Beaumont, France.,Department of Digestive Surgery, CHU Estaing, Clermont-Ferrand, France
| |
Collapse
|
42
|
Association of mechanical bowel preparation with oral antibiotics and anastomotic leak following left sided colorectal resection: an international, multi-centre, prospective audit. Colorectal Dis 2018; 20 Suppl 6:15-32. [PMID: 30255646 DOI: 10.1111/codi.14362] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/30/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The optimal bowel preparation strategy to minimise the risk of anastomotic leak is yet to be determined. This study aimed to determine whether oral antibiotics combined with mechanical bowel preparation (MBP+Abx) was associated with a reduced risk of anastomotic leak when compared to mechanical bowel preparation alone (MBP) or no bowel preparation (NBP). METHODS A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 Left Sided Colorectal Resection audit was performed. Patients undergoing elective left sided colonic or rectal resection with primary anastomosis between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak. RESULTS Of 3676 patients across 343 centres in 47 countries, 618 (16.8%) received MBP+ABx, 1945 MBP (52.9%) and 1099 patients NBP (29.9%). Patients undergoing MBP+ABx had the lowest overall rate of anastomotic leak (6.1%, 9.2%, 8.7% respectively) in unadjusted analysis. After case-mix adjustment using a mixed-effects multivariable regression model, MBP+Abx was associated with a lower risk of anastomotic leak (OR 0.52, 0.30-0.92, P = 0.02) but MBP was not (OR 0.92, 0.63-1.36, P = 0.69) compared to NBP. CONCLUSION This non-randomised study adds 'real-world', contemporaneous, and prospective evidence of the beneficial effects of combined mechanical bowel preparation and oral antibiotics in the prevention of anastomotic leak following left sided colorectal resection across diverse settings. We have also demonstrated limited uptake of this strategy in current international colorectal practice.
Collapse
Affiliation(s)
-
- European Society of Coloproctology (ESCP) Cohort Studies Committee, Department of Colorectal Surgery, University of Birmingham, Birmingham, UK
| |
Collapse
|
43
|
Cirocco WC, Ellison EC. 75 years of the Central Surgical Association: The last quarter century. Surgery 2018; 164:626-639. [PMID: 30093280 DOI: 10.1016/j.surg.2018.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 06/21/2018] [Indexed: 10/28/2022]
Affiliation(s)
- William C Cirocco
- The Ohio State University, Wexner College of Medicine, Department of Surgery, N711 Doan Hall, 410 West 10th Avenue, Columbus, OH.
| | - E Christopher Ellison
- The Ohio State University, Wexner College of Medicine, Department of Surgery, N711 Doan Hall, 410 West 10th Avenue, Columbus, OH
| |
Collapse
|
44
|
Liu Z, Yang M, Zhao ZX, Guan X, Jiang Z, Chen HP, Wang S, Quan JC, Yang RK, Wang XS. Current practice patterns of preoperative bowel preparation in colorectal surgery: a nation-wide survey by the Chinese Society of Colorectal Cancer. World J Surg Oncol 2018; 16:134. [PMID: 29986735 PMCID: PMC6038260 DOI: 10.1186/s12957-018-1440-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/04/2018] [Indexed: 02/07/2023] Open
Abstract
Background The optimal preoperative bowel preparation for colorectal surgery remains controversial. However, recent studies have established that bowel preparation varies significantly among countries and even surgeons at the same institution. This survey aimed to obtain information on the current practice patterns of bowel preparation for colorectal surgery in China. Methods A paper-based survey was circulated to the members of the Chinese Society of Colorectal Cancer (CSCC). The survey responses were collected and analyzed. Statistical analysis was performed for all the categorical variables according to the responses to individual questions. Results Three hundred forty-one members completed the questionnaire. Regarding surgical practice, 203 (59.5%) performed > 50% of the colorectal operations laparoscopically or robotically; the use of mechanical bowel preparation (MBP) alone was significantly higher (63.5 vs 31.9%; P < 0.001). The respondents who performed > 200 colonic or rectal resections provided significantly more MBP alone (79.6 vs 39.1%, P < 0.001; 76.6 vs 43.2%, P < 0.001; respectively). Among hospitals with fewer than 500 beds, 52.4% of the respondents used MBP + oral antibiotics preparation (OAP) + enema, a significantly higher percentage than the respondents of hospitals with more than 500 beds (P < 0.001). Nearly 40% of the respondents prescribed OAP in regimens; meanwhile, 74.8% prescribed preoperative intravenous antibiotics. Conclusions The study demonstrates considerable variation among members from the CSCC. These findings should be considered when developing multicenter trials and to provide more definitive answers. Electronic supplementary material The online version of this article (10.1186/s12957-018-1440-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Zheng Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Yang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Xun Zhao
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu Guan
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zheng Jiang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hai-Peng Chen
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Song Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ji-Chuan Quan
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Run-Kun Yang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Shan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| |
Collapse
|